Osteoarthritis (OA) is a chronic degenerative disease characterized by recurrent joint pain and progressive joint motion disorders. The main pathological changes are progressive destruction of the affected articular cartilage, cartilage degeneration and subchondral bone sclerosis, which are essentially imbalances in the catabolism and anabolism of the articular cartilage matrix. With the development of an aging population, osteoarthritis has become a major disease that endangers the physical and mental health of the elderly, and the knee joint is one of the most vulnerable joints.
1. Risk factors for the occurrence of osteoarthritis of the knee (KOA).
(1) Injury: intra-articular fracture, meniscal injury, patellar dislocation and other causes of articular cartilage damage;
(2) Excessive weight-bearing: excessive weight-bearing on the joint surface due to obesity or internal or external deformity of the knee joint, and the knee joint of obese and overweight elderly people is susceptible to this disease;
(3) Infection or inflammation causing destruction of articular cartilage;
(4) subchondral bone necrosis, such as dry brittle osteoarthritis occurs intra-articular free bodies, resulting in damage to the articular cartilage surface.
2.Treatment methods
Non-surgical treatment should be tailored and individualized according to the patient’s age, occupation, and degree of joint damage. An appropriate treatment plan that helps to relieve joint pain and stiffness, improve joint mobility, and improve the patient’s quality of life includes physical therapy and/or specialized therapy, exercise, weight control, patient education, and medication.
2.1 Medication Medication plays an important role in the treatment of osteoarthritis of the knee, but the complex mechanism of knee osteoarthritis pain, joint swelling, pain, and increased synovial fluid are not absolute indications for the use of anti-inflammatory and analgesic drugs. When sports exercise, physical therapy and other therapeutic measures are ineffective, non-steroidal anti-inflammatory drugs (NSAIDS) can be added. The dose and interval of administration can be determined according to the in vivo metabolic characteristics of the drug and the patient’s response to the drug, and the dose can be adjusted in the course of treatment. Commonly used drugs are.
(1)Analgesics;
(2) non-steroidal anti-inflammatory drugs;
(3) cartilage nutrition drugs;
(4) steroidal anti-inflammatory drugs;
(5) Hyaluronic acid. The routes of administration are oral, topical and joint lavage.
2.1.1 The most commonly used analgesic is paracetamol (acetaminophen), which was recommended as the first-line drug for knee osteoarthritis by the European Rheumatism Association in 2000. It is safe and effective, well tolerated, and can relieve knee pain below the moderate level, but it is not effective for more severe pain.
2.1.2 Non-steroidal anti-inflammatory drugs (NSAIDs) are traditionally used in the treatment of osteoarthritis, the mechanism of action is to prevent the synthesis of prostaglandins, which plays an analgesic and anti-inflammatory role, but also reduces the role of prostaglandins in protecting the gastric mucosa, which can lead to gastric discomfort, and in severe cases lead to gastric ulcers or bleeding and other side effects. toheed et al. considered etodolac (600 ml/d) to be the most effective, while anti-inflammatory pain Perkins found that anti-inflammatory pain increased the rate of joint degeneration. In order to reduce the side effects of NSAIDs, they are made into emulsions for topical application, such as Fotarine emulsion, which are applied topically to relieve joint pain.
2.1.3 Chondrotropic drugs are increasingly used, such as glucosamine sulfate, chondroitin sulfate and so on. The effect of these drugs is better than that of non-steroidal anti-inflammatory drugs, and the drugs are slow to take effect, mostly after 4-6 weeks, and the effect lasts for 4-8 weeks after stopping the drugs. Chondroitin sulfate is a physiological substance necessary for the synthesis of proteoglycan and hyaluronic acid by chondrocytes, which can block the pathological process of osteoarthritis and inhibit enzymes that can damage cartilage, but does not inhibit the synthesis of prostaglandins, and has a mild anti-inflammatory effect. Chondroitin sulfate is well absorbed orally, inhibits proteoglycan and collagen catabolism, stimulates the synthesis of cartilage layer structure, has no effect on normal cartilage, only on diseased articular cartilage, and has a general pain-relieving effect, but can significantly improve joint function.
2.1.4 Hyaluronic acid (HA) Discovered in 1936 by Meyer et al. from the vitreous humor of bull’s eye, sodium hyaluronate (SA) is a derivative of hyaluronic acid with a larger molecular weight and better viscoelasticity. In patients with osteoarthritis of the knee joint, the lubrication and shock absorption capacity of the synovial fluid is reduced, and the content of hyaluronic acid molecules is decreased. Hyaluronic acid is a long-chain macromolecular substance abundant in the synovial fluid, and under normal conditions, it is entangled with each other to form a net-like structure, which maintains the rheological properties of normal synovial fluid.
Recently, hyaluronic acid is not only the main component of synovial fluid, but also the surface component of articular cartilage. It can be dissolved in synovial fluid, reduce friction during low-speed movement, absorb shock during high-speed movement, have a strong inhibitory effect on the excitability of synovial membrane and its underlying nociceptive receptors and sensory fibers, relieve joint pain, and have a barrier effect and anti-inflammatory effect. Injection of hyaluronic acid or its derivatives into the joint cavity is a means of treatment. The total effective rate of sodium glassate injection for osteoarthritis of the knee was 96.3% after 5 weeks, with no significant toxic side effects, and after 16 months of discontinuation, 74% of patients had no recurrence. However, this method also has side effects such as septic infection of the joint and aseptic acute arthritis.
2.1.5 Intra-articular injection of glucocorticoids can stabilize the damaged lysosomal membrane, prevent the release of proteolytic enzymes, inhibit the activity of released enzymes, inhibit mast cell and histamine activity, and reduce the synthesis of prostaglandins by inhibiting the synthesis of arachidonic acid from cellular phospholipids, thus reducing inflammation and immune response, but it can inhibit the synthesis of proteoglycan and collagen, and the damage to cartilage increases with The damage to cartilage increases with the injection of hormones and should not be used in general.
2.2 Exercise Slow, gentle extension activities will help prevent joint stiffness, such as yoga and tai chi, and aerobic exercises that are both therapeutic and recreational, such as walking and swimming. Exercise can strengthen the quadriceps, enhance joint stability, and strengthen the soft tissue toughness of the knee, while mechanical stress regulates the synthesis and degeneration of the cartilage layer. Exercise can also lose weight, reduce weight pressure on weight-bearing joints, reduce the risk factors for osteoarthritis, reduce joint damage, and improve joint function. It is easy to implement and less costly. Doctors can develop an exercise program suitable for individual patients according to their different conditions and carry out the program in a step-by-step manner, which can effectively reduce the pain of the disease.
2.3 Health education and lifestyle change for patients. It has been suggested that the application of large amounts of antioxidant micronutrients, especially vitamin C, can reduce the risk of cartilage loss in the knee joint and slow down the development of osteoarthritic lesions. As people become more health-conscious, good lifestyle practices such as diet and nutrition and weight loss are receiving more attention in the treatment of osteoarthritis, and guidelines for exercise and weight loss are being given more priority than pharmacotherapy.
2.4 Physical and professional treatment correctly uses hot and cold therapy with the aid of assistive devices such as crutches, slings or shoe inserts, installation of necessary splints and supports, and guidance on the correct use of joints. Mineral bath, sand therapy, infrared physiotherapy, low-energy laser, magnetic therapy, external application of herbs for blood circulation and blood stasis, fumigation, immersion, acupuncture, etc., can be applied as adjuvant therapy to receive better results, relieve pain, delay the course of disease, and significantly reduce the dosage of non-steroidal anti-inflammatory drugs.
2.5 Tui Na manipulation therapy
Chinese medicine injury manipulation has the effect of improving blood circulation, eliminating swelling, relieving muscle spasm, reducing pain and enhancing the function of knee joint movement. The treatment methods are:
( 1) Relaxation method: The patient lies flat, the practitioner presses the soft tissues of the upper, lower, inner and outer knee patella in order with the belly of the thumb, focusing on the pressure and pain area, for about 10 minutes.
( 2) Prominence rubbing method: The patient is lying down, the physician fixes the patella with the thumb, index and middle finger of both hands, and pushes the patella in the upward, downward, internal, external and internal-upward and internal-downward directions several times in sequence, focusing on the direction of resistance to movement, and then lightly presses the palm of the patella in a circular motion, causing the patella to rub against the cartilage surface of the femoral condyle, for about 10 minutes.
( 3) Point pressure method: The patient lies on his back, the practitioner is positioned on his affected side, rubbing the blood sea, Liangqiu point and around the patella; using the thumb to massage the inner and outer knee eyes, using the rubbing method on both sides of the knee joint, flexing and extending the knee joint and using the tip of the middle finger to press on the Guizhong point with light to heavy force, and finally using the palm to rub the patella in a circular motion, for about 10 minutes.
( 4) Pulling knee method: The patient lies prone, the doctor blocks the patient’s knee fossa with one hand and holds the ankle joint with the other hand to assist the knee joint of the affected limb to straighten and flex out passively, repeat several times, gradually increase the knee extension and flexion, about 5 minutes.
( 5) Knee hugging method: The patient lies on his back, the doctor puts both hands on the inner and outer side of the knee joint, hugging and kneading or one up and one down, kneading and rubbing together with knee flexion and extension movements, about 10 minutes.
2.6 External treatment with Chinese medicine
2.6.1 Fumigation and hot ironing method
Put the Chinese herbal remedy (10g each of Chuan Wu, Cao Wu, Ze Lan, Di Long, Niu Knee, Gui Zhi and Gan Cao, 15g each of Hai Tong Pi, Wei Ling Xian and Tu Fu Zi, 6g each of Frankincense and Myrrh) in gauze, put it in about 4,000mL of water, boil it and then decoct it for about 25min over moderate heat, add 5 tablespoons of vinegar, let the water temperature drop to 40℃, and soak the affected knee repeatedly. Or put it in a cloth bag and heat it under water, then iron the affected knee.
2.6.2 Chinese herbal compress method
The ointment was prepared as follows: 1 black chicken, 2 white flower snakes, 1 pair of mealybug, 30 centipedes, 1 snapping turtle, and 1 pair of Andrographis paniculata, Haitongpi, Qianxianjian, Guanzhong, Angelica sinensis, Chuanwu, Tianma, Safflower, Sinapis lucidum, Lycium barbarum, Dioscorea, Cangerzi, Citrus aurantium, Wu Lingliao, Haima, Gentiana, Thornbush, Gao Liangjian, Ocimum sanctum, Aconite, Platycodon grandiflorum, Peach kernel, Wu Wei Zi, Soapberry, Radix et Rhizoma gastrodiae. Ginger, Boswellia, Gum, Ligustrum, Knotweed, Turtle Worm, Hooked Vine, Clove, Blood and Yu Char, Wattle Tea, Dog’s Bone, Shen Xiang, Elephant Bark, Radix et Rhizoma Polygonati each 60g, Shang Lu, Deer Antler, Amber, Panax notoginseng, Strychnine each 30g, Ginger, Boswellia, Myrrh, Pericarpium, Scorpion, Cinnamomum, Rhizoma, Rhizoma Ligusticum, Rhizoma Chuanxiong, Fructus, Fructus, Rhizoma Bark, Radix et Rhizoma Dioscoreae, Cortex Eucommiae, Compositae, Phellodendron, Hematopoeia, Atractylodes, Papaya The above herbs were made into a solid hard ointment according to the Chinese Medicine Preparation Manual. 100g of the ointment was spread on a white cloth and wrapped around the affected knee and changed once every 2 weeks.
2.6.3 Chinese medicine ionization method
The Chinese herbal medicines were selected from Angelica Sinensis and Radix Paeoniae each 20g, Wei Ling Xian, Epimedium, Radix Rehmanniae, Qiang Wu, Dou Wu, Fang Feng, Liu Liu Liu Nuo, Yan Hu Suo, Gui Zhi, Hessian and Cang Zhu each 15g, Safflower and Mu Xiang each 10g, placed in a medicine pot, added 500mL of water, soaked for 2h and then decocted for 30min, the liquid was prepared and introduced into the affected area with an ionizer.
2.7 Combination of internal and external treatment with Chinese medicine
The treatment of osteoarthritis of the knee joint in Chinese medicine is generally based on the identification of liver and kidney deficiency and blood stasis, phlegm and dampness blocking the ligaments, and the treatment is to tonify the liver and kidney, warm up the meridians, activate blood stasis, strengthen the spleen and resolve phlegm. In the middle and late stages, the treatment was based on nourishing the blood, tonifying the liver and kidney, supplemented with herbal medicines to warm the meridians, regulate qi and disperse nodules, and treated with the self-designed kidney and bone strengthening soup (dog’s spine, sequestra, mulberry, bonesetter, wei ling xian, papaya, cow knee, etc.) combined with ionization. There were 106 cases treated with the non-steroidal anti-inflammatory drug Futalin tablets orally and Futalin emulsion externally, compared with 52 cases treated with the non-steroidal anti-inflammatory drug Futalin.
Results: The treatment of osteoarthritis of the knee with Chinese herbal medicine iontophoresis was effective with few side effects. The treatment of osteoarthritis of the knee was carried out by using Chinese medicine (30g of Radix Rehmanniae, 20g each of Radix Angelicae Sinensis, Radix Achyranthes Bidentatae, 20g each of Radix Angelicae Sinensis, Radix Achyranthes Bidentatae, 15g each of Rhizoma Chuanxiong, Fructus Lycii, Radix Astragali, Radix et Rhizoma Mullein, Radix et Rhizoma Wailingensis, 10g each of Radix et Rhizoma Dulcis) internally and externally (5g of Safflower, 30g of Salviae Miltiorrhizae, 0.5g of Strychnine, 5g each of Radix et Rhizoma Chuanwu, 2 centipedes, 2g of ice chips with vinegar cloth).
2.8 Surgical treatment
2.8.1 Incisional cleanup under direct vision Maghuson (1941) was the first to advocate this, with an excellent rate of 65% to 75%. It is suitable for obese women over 40 years of age with swollen and painful joints, obvious bony bulge at the joint edges, free bodies in the joints, relatively intact weight-bearing joints, and poor results of conservative therapy.
2.8.2 Arthroscopic debridement has both diagnostic and therapeutic effects. It mainly includes synovial debridement, articular surface repair, drilling of cartilage defects, resection of bony redundancy, release of adhesions, release of the lateral patellar support band, repair of the ruptured meniscus, and removal of the free body, etc. It has the advantages of less damage and faster postoperative recovery, but it is not effective for those with obvious damage to the knee joint and deformed internal and external rotation angles, and artificial arthroplasty is required.
2.8.3 Tibial high osteotomy The tibial high osteotomy can restore the normal alignment of the knee joint and make it conform to the biomechanical axis to reduce the symptoms and delay the development of arthritis; at the same time, it can make full use of the favorable conditions of the healthy joint cartilage to partially repair the degenerating joint. It is suitable for younger patients and those with mild joint wear and tibial plateau bone collapse of up to 0.5 cm, especially for patients under 60 years of age as a measure to delay or eliminate joint replacement.
2.8.4 Knee fusion is indicated for young patients with solitary severe osteoarthritis of the knee engaged in physical activity.
2.8.5 Artificial joint replacement is indicated for elderly patients with more bone and joint destruction and severe pain.
2.8.6 Others Periosteal and chondroperiosteal grafts and transfers with subchondral bone have been used clinically, but the formation of hyaline cartilage is poorly tolerated mechanically. Autologous chondrocyte transplantation is more promising. Prechondrocytes are obtained from other parts of the body (sacroiliac joint), mixed with growth factors and synthetic matrix system in vitro, and cultured artificially and aseptically. However, the difficulties of this method are that it is technically complex and expensive, and the long-term efficacy needs to be further investigated.
The incidence of this disease is increasing, knee OA in the treatment of non-surgical treatment such as Chinese herbal medicine, acupuncture, massage, fumigation, hydrotherapy, physical therapy, injection therapy, etc., has achieved some successful experience, the use of non-surgical treatment is an important choice in the clinical treatment of this disease. At present, because Western medicine still lacks effective means of prevention and treatment of this disease, non-surgical treatment, especially Chinese medicine has accumulated considerable clinical experience in the treatment of this disease, but there is still a need to integrate the advantages of a variety of therapies, explore new ideas of traditional and modern medicine, combined with the characteristics of this disease, and gradually establish a more systematic and reasonable treatment of this disease comprehensive program, hoping to make important progress in non-surgical treatment.
Although many advances have been made in the study of OA, there is a common problem in these studies, instead of focusing on the understanding and regulation of intracellular processes leading to apoptosis of articular cartilage cells, the destruction of cartilage is expected to be relied on the proliferation and repair of chondrocytes. Since articular cartilage is a specialized connective tissue without blood vessels, nerves and lymph, and because of the low renewal rate of chondrocytes and their poor ability to repair themselves, once cartilage damage begins in OA patients, the rate of destruction is faster than the rate of self-repair. Moreover, the etiology and mechanism of articular cartilage cell damage are very complicated, so there is no effective method to stop the progressive destruction of articular cartilage.
It is believed that with the development of medical molecular biology, computer-aided design, nano-biotechnology, and the successful implementation of the human genome project and post-genome project, the advantages of Chinese medicine in treating untreated diseases will be fully utilized, and the effects of Chinese medicine, especially liver and kidney drugs, on the immune response, chondrocyte metabolism and cytokine activity of the body will be further studied, and Chinese and Western medicine will be organically combined to give full play to the advantages of Chinese medicine, which is simple, convenient, effective and inexpensive. In the end, it will open up a broad prospect for the prevention and treatment of OA.